Stress Testing – Help From Dr. Morgenstern Of First10EM

Update 4-11-2019: Dr. Morganstern has made an outstanding podcast, Journal Jam 15 Cardiac Stress Testing After Negative ED Workup for MI on Emergency Medicine Cases. Review the podcast and the posts below. His insights are useful for all primary care clinicians.


(1) Stress Test Evidence: Introduction by Dr. Justin Morgenstern |Published March 12, 2019 from First10EM.

(2) Stress Tests Part 1: How often do we miss MI?

(3) Stress Tests Part 2: Defining Cardiovascular Outcomes

(4) Stress Tests Part 3: Stress test accuracyt by Dr. by |Published 

(5) Stress Tests Part 4: Revascularization and the Value of Stenting by Dr. by |Published 

(6) Stress Tests Conclusion: Putting it all together by Dr. Justin Morgenstern|Published March 15, 2019

Additional References For Cardiac Stress Testing From The Show Notes Of The Podcast. These are the articles Dr. Morganstern discussed in the podcast:

(1)Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342:(16)1163-70.

(2) Scheuermeyer F, Innes G, Grafstein E, et al. Safety and Efficiency of a Chest Pain Diagnostic Algorithm With Selective Outpatient Stress Testing for Emergency Department Patients With Potential Ischemic Chest Pain. Annals of Emergency Medicine. 2012;59(4):256-264.

(3) Meyer MC, Mooney RP, Sekera AK. A critical pathway for patients with acute chest pain and low risk for short-term adverse cardiac events: role of outpatient stress testing. Annals of emergency medicine. 2006; 47(5):427-35.

(4) Manini AF, McAfee AT, Noble VE, Bohan JS. Prognostic value of the Duke treadmill score for emergency department patients with chest pain. The Journal of Emergency Medicine. 2010;39(2):135-143.

(4) Amsterdam EA, Kirk JD, Diercks DB, Lewis WR, Turnipseed SD. Immediate exercise testing to evaluate low-risk patients presenting to the emergency department with chest pain. Journal of the American College of Cardiology. 2002; 40(2):251-6.

(5) Sanchis J, Bodí V, Núñez J, et al. Usefulness of early exercise testing and clinical risk score for prognostic evaluation in chest pain units without preexisting evidence of myocardial ischemia. The American journal of cardiology. 2006; 97(5):633-5.

(6) Sandhu AT, Heidenreich PA, Bhattacharya J, Bundorf MK. Cardiovascular Testing and Clinical Outcomes in Emergency Department Patients With Chest Pain. JAMA internal medicine. 2017; 177(8):1175-1182.

(6) Froelicher VF, Lehmann KG, Thomas R, et al. The electrocardiographic exercise test in a population with reduced workup bias: diagnostic performance, computerized interpretation, and multivariable prediction. Veterans Affairs Cooperative Study in Health Services #016 (QUEXTA) Study Group. Quantitative Exercise Testing and Angiography. Ann Intern Med. 1998;128:(12 Pt 1)965-74.

(7) Colon PJ, Guarisco JS, Murgo J, Cheirif J. Utility of stress echocardiography in the triage of patients with atypical chest pain from the emergency department. The American journal of cardiology. 1998; 82(10):1282-4, A10.

(8) Gurunathan S, Young G, Parsons G, et al. 132 Diagnostic Accuracy of Stress Echocardiography Compared with Invasive Coronary Angiography with Fractional Flow Reserve for The Diagnosis of Haemodynamically Significant Cad in Patients with Known or Suspected CAD Heart. 2016; 102(Suppl 6):A94-A95.

(9) de Jong MC, Genders TS, van Geuns RJ, Moelker A, Hunink MG. Diagnostic performance of stress myocardial perfusion imaging for coronary artery disease: a systematic review and meta-analysis. European radiology. 2012; 22(9):1881-95.

(10) Young LH, Wackers FJ, Chyun DA, et al. Cardiac outcomes after screening for asymptomatic coronary artery disease in patients with type 2 diabetes: the DIAD study: a randomized controlled trial. JAMA. 2009;301:(15)1547-55.

(11) Khare RK, Powell ES, Venkatesh AK, Courtney DM. Diagnostic uncertainty and costs associated with current emergency department evaluation of low risk chest pain. Critical pathways in cardiology. 2008; 7(3):191-6.

(12) Napoli AM. The association between pretest probability of coronary artery disease and stress test utilization and outcomes in a chest pain observation unit. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2014; 21(4):401-7.

(13) Lim SH, Anantharaman V, Sundram F, et al. Stress myocardial perfusion imaging for the evaluation and triage of chest pain in the emergency department: A randomized controlled trial. J. Nucl. Cardiol.. 2013; 20(6):1002-1012.

(14) (Frisoli TM, Nowak R, Evans KL, et al. Henry Ford HEART Score Randomized Trial. Circ Cardiovasc Qual Outcomes. 2017; 10(10).

(16)Foy AJ, Liu G, Davidson WR, Sciamanna C, Leslie DL. Comparative effectiveness of diagnostic testing strategies in emergency department patients with chest pain: an analysis of downstream testing, interventions, and outcomes. JAMA internal medicine. 2015; 175(3):428-36.

(17) Fanning JP, Nyong J, Scott IA, Aroney CN, Walters DL. Routine invasive strategies versus selective invasive strategies for unstable angina and non-ST elevation myocardial infarction in the stent era. The Cochrane database of systematic reviews. 2016.

(18) Khan SU, Singh M, Lone AN, et al. Meta-analysis of long-term outcomes of percutaneous coronary intervention versus medical therapy in stable coronary artery disease. European journal of preventive cardiology. 2018.

(19) Mahler SA, Riley RF, Hiestand BC, et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes. 2015;8(2):195-203.

(20) Tomaszewski CA, Nestler D, Shah KH, Sudhir A, Brown MD. Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non-ST-Elevation Acute Coronary Syndromes. Ann Emerg Med. 2018;72(5):e65-e106.

(21) Amsterdam E, Wenger N, Brindis R, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(25):e344-426.

(22) Natsui S, Sun BC, Shen E, et al. Evaluation of Outpatient Cardiac Stress Testing After Emergency Department Encounters for Suspected Acute Coronary Syndrome. Ann Emerg Med. 2019; in press



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